Healthcare Provider Details

I. General information

NPI: 1427730357
Provider Name (Legal Business Name): LYTLE FAMILY DENTISTRY & ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14739 MAIN STREET
LYTLE TX
78052
US

IV. Provider business mailing address

14739 MAIN STREET
LYTLE TX
78052
US

V. Phone/Fax

Practice location:
  • Phone: 830-772-4567
  • Fax: 830-772-9804
Mailing address:
  • Phone: 830-772-4567
  • Fax: 830-772-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN JAY CROCKER
Title or Position: DENTIST
Credential: DDS
Phone: 830-772-4567